Welcome to the CAF PCI Registry March 2022 case scenario. This month, we will cover sequence number 4561, the Canadian Study of Health and Aging or CSHA Clinical Frailty Scale. A 40-year-old female is outside training for a 5K during her lunch hour when she experiences unexplained abrupt severe shortness of breath. She cuts her training short and returns to her office to recover. However, after resting, her shortness of breath does not completely resolve. Her coworkers become concerned and call 911. Upon EMS arrival, she is sitting in a chair at her desk in visible respiratory distress. An immediate ECG is performed, which reveals ST depressions. Her vital signs are as follows, blood pressure 140 over 110, heart rate 112, and oxygen saturation 90% on room air. She has no medical history and takes no medications daily. The decision to transport to the nearest emergency department is made, and she requires assistance to move from her chair to the EMS stretcher. The triage nurse notes continued shortness of breath and places her on two liters of oxygen, raising her O2 sats to 97%. Her lungs are clear. She is awake and alert with warm and dry skin. She is wheeled to room 15, where she requires assistance out of the ED stretcher due to her symptoms. EMS ECG is given to the ED physician, who notes the ST depressions are consistent with the posterior MI, and the cath lab is activated. Our first question, when there is no specific documentation identifying the patient's frailty status, can descriptive documentation be used to code sequence number 4561? Number one, yes, or number two, no? And the answer is number one, yes. Descriptive documentation of the patient's current condition in the medical record that meets the definition is satisfactory. For example, the patient reports they are normally active but unable to ambulate on arrival due to pain would equal to vulnerable. As well, physician documentation of a specific frailty scale will support coding. And the example of the patient is vulnerable. Our follow-up question, what documentation in the medical record can be used for coding sequence number 4561? Number one, physician documentation. Number two, nurse documentation. Number three, EMS documentation. Or number four, any of the prior three? And the answer is number four, any. Documentation found anywhere in the patient's legal medical record is used for coding data elements when the data definition and target values are met and must be present in the event of an audit. Our next question, how would sequence number 4561 be coded based on the documentation available? Number one, vulnerable. Number two, well. Or number three, moderately frail. Please take a few moments to review the documentation prior to making your final selection. And the answer is number one, vulnerable. The Canadian Study of Health and Aging, or CSHA, clinical frailty scale in sequence number 4561 is capturing the last value prior to the start of the first procedure. In other words, the most recent symptoms, clinical status of a patient will impact how this data element is coded. Let's now take a moment to put all the pieces together. So we know we have an active female who is overall healthy, has no prior medical history, and takes no medications on a daily basis. However, her symptoms of shortness of breath now limit her ability to do previously simple activities like moving from a stretcher to another stretcher. And this is now the frailty status we want to capture. And when using the infographic for the CSHA clinical frailty scale located on the CAP PCI resources page, you can see the story of this patient's meeting the descriptive definition of being vulnerable. To be more specific, while the patient is not dependent on others for daily help as evidenced by running to prepare for a 5K, the fact that she works ascertains independency. And being overall healthy, her symptoms of shortness of breath limits her activities of basic movement when she needs assistance moving from chair to stretcher and even stretcher to stretcher. Thank you for viewing the March 2022 CAP PCI Registry case scenario. We'll see you next month.

CAF PCI Registry

case scenario

shortness of breath

myocardial infarction

CSHA Clinical Frailty Scale